后路全脊椎截骨矫形术治疗重度胸腰椎角状后凸/侧后凸的中远期效果观察

Posterior vertebral column resection(PVCR) corrective surgery for moderate to severe focal kyphosis/kyphoscoliosis in the thoracolumbar spine

中文关键词:  角状后凸畸形  后路全脊椎截骨矫形术  胸腰椎侧后凸畸形

英文关键词:Focal kyphosis  Posterior vertebral column resection  Thoracolumbar kyphoscoliosis

中文摘要:

  【摘要】 目的：评价中重度胸腰椎角状后凸/侧后凸畸形行后路全脊椎截骨矫形术患者的中远期影像学和临床疗效。方法：总结2004年5月～2016年6月于我院行后路全脊椎截骨矫形术（posterior vertebral column resection，PVCR）的68例中重度胸腰椎角状后凸/侧后凸患者的临床资料，其中男性37例，女性31例，平均年龄36.89±15.38岁。45例患者术前存在下肢神经症状，Frankel分级A级1例，B级2例，C级9例，D级33例。病因诊断：结核性后凸50例，先天性后凸18例。所有患者均行手术前后和随访时的后凸局部和全脊柱X线、CT、MRI检查，确定后凸顶点，并测量后凸角度。对合并侧凸的21例患者测量侧凸角度。在全脊柱X线片上评价患者的矢状位和冠状位平衡状况。临床评价包括下肢神经功能的Frankel分级，生活质量的Oswestry功能障碍指数（Oswestry disability index，ODI），腰背部疼痛的视觉模拟评分（visual analogue score，VAS），以及患者的手术治疗满意度（patient satisfactory index，PSI）。将患者依照年龄、后凸病因、后凸严重程度（后凸角度）、后凸顶椎节段、术前Frankel分级和有无并发症分组，进行影像学和临床结果比较，并对随访ODI评分改善率的影响因素进行多元回归分析。结果：患者平均随访时间为41.47±4.68个月（36～96个月）。患者术前平均后凸角度94.14°±22.57°（60.0°～155.2°），术后减少至31.92°±16.79°，末次随访时为34.60°±18.09°，后凸矫正率为（64.26±15.13）%。21例同时伴有侧凸的患者术前平均侧凸角度37.36°±26.19（12.0°～107.0°），术后减少至13.21°±14.72°，末次随访时为14.33°±14.93°，侧凸矫正率为（69.70±28.44）%。末次随访时，30例患者Frankel分级改善，3例患者从A级或B级提高到C级，5例患者从C级提高到D级，1例患者从C级提高到E级，21例患者从D级提高到E级。术后平均ODI改善率为（48.82±33.99）%，平均VAS改善率为（64.03±21.42）%；患者PSI为91.2%。对后凸矫正率、ODI改善率的单因素分析结果提示，后凸角度小于95°和年龄小于35岁时，后凸矫正率更高；当患者角状后凸顶点位于T10或以下，术前双下肢无神经症状，或围手术期无并发症发生时，其临床改善率更高。多因素回归分析结果发现，术前后凸角越小，随访时后凸角矫正度数越大，术前Frankel分级为D或E级，其ODI改善率越高。中远期发生内固定失败6例（8.8%），均行翻修手术。结论：后路全脊椎截骨矫形术是治疗胸腰椎中重度角状后凸/侧后凸畸形的一种有效、安全的方法，中长期随访结果发现患者可获得满意的畸形矫正效果以及良好的神经功能改善。

英文摘要:

  【Abstract】 Objectives: To evaluate the radiological and clinical outcomes of the corrective surgery for patients with moderate to severe focal kyphosis/kyphoscoliosis in thoracolumbar spine. Methods: 68 patients with moderate to severe focal kyphosis/kyphoscoliosis of the thoracolumbar spine underwent posterior vertebral column resection(PVCR) at our hospital. There were 37 males and 31 females, with a mean age of 36.89±15.38 years. There were 45 patients with lower extremity neurological symptoms before operation, preoperative Frankel classification was as follows: 33 cases of grade D, 9 cases of grade C, 2 cases of grade B, and 1 case of grade A. The kyphosis level radiographs were obtained from all patients preoperatively, immediately postoperatively and at final follow-ups. Local kyphosis and scoliosis Cobb angles were measured. Full-spine standing radiographs were obtained before surgery and at follow-ups, and the spine sagittal and coronal balances were evaluated. The Frankel grading system for neurological functions, the Oswestry disability index(ODI) for life quality, the visual analogue score(VAS) for back pain and the patient satisfactory index(PSI) for satisfaction to surgery were applied before surgery and at follow-ups. The radiological and clinical outcomes were further analyzed in different sub-groups of patients according to etiology, severity of kyphosis, age, level of kyphosis apex, Frankel grade before surgery, and complications. The factors influencing the improvement rate of follow-up ODI score were analyzed by multiple regression. Results: The average follow-up time of patients was 41.47±4.68 months. The average kyphosis angle reduced from 94.14°±22.57° before surgery to 31.92°±16.79° after surgery, and was 34.60°±18.09° at final follow-up, the correction rate of kyphosis was (64.26±15.13)%. The average scoliosis angle of 21 patients reduced from 37.36°±26.19° to 13.21°±14.72° after surgery, and was 14.33°±14.93° at final follow-up, the correction rate of scoliosis was (69.70±28.44)%. At final follow-up, Frankel classification was improved in 29 patients, 3 patients were raised from grade A or B to C, 5 patients from grade C to D, 1 patient from grade C to E, and 21 patients from grade D to E. The sagittal balance of the spine, Frankel grading, ODI and VAS scores were improved. The PSI showed a satisfied rate of 91.2%. The correction rate was significantly higher in patients with kyphosis angle less than 95° and aged less than 35 years. The clinical improvement rate was significantly higher in patients with kyphosis apex at lower thoracic spine or thoracolumbar segment, preoperative Frankel grade E and without postoperative complications. The results of multiple regression analysis showed that the smaller the kyphosis angle before surgery, the larger the degree of kyphosis angle correction was, and with Frankel grade D or E comparing with A-C the ODI improvement rate was higher. The instrumentation failure happened in 6 patients and underwent revision surgery. Conclusions: Posterior vertebral column resection(PVCR) is an effective and safe technique for the treatment of moderate to severe focal kyphoscoliosis. Medium- and long-term follow-up results show that satisfactory results of correction and improvement of nerve function could be obtained.